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Dr. Caroline Ramsey Musselwhite

Tuesday, April 24, 2018

Building Augmentative Communication Skills in Homes Where English and Spanish are Spoken: Perspectives of an Evaluator/Interventionist

(Hopefully this will turn in to an article for the ASHA Special Interest Groups Perspectives)


Introduction

Deanna K. Wagner, MS/CCC-SLP, is a speech-language pathologist with over 25 years experience providing consultations and training in the area of assistive technology with an emphasis on augmentative communication. Through Southwest Human Development Easter Seals she has participated in many projects related to balanced literacy and AAC.  She is one of the founding members of Out & About, a local AAC in the Community special interest group.  She has presented at local, national, and international conferences.
Financial Disclosures:  She is contracted to work with educators and families to achieve goals in the area of AAC selection and implementation through NAU and TherapyOne, as one of few evaluators/trainers who can support families who speak primarily Spanish.  She also provides ongoing AAC training to adults at Valley Life Adult Day Treatment Program.
Non-financial Disclosures:  She has been invited to provide feedback and input as vocabulary files and apps were being developed for a number of vendors: Alexicom, Assistiveware, Prentke Romich Company, Semantic Compaction, TobiiDynavox.

Background

AAC users (and their families) receiving services from Deanna have varied tremendously over the past 25 years, the youngest barely two years old and the oldest in her sixties.  Almost all have qualified for long-term care assistance, which means that they have autism, cerebral palsy, or developmental delays that result in reliance on others throughout their lifetime for daily care.  Arizona (AZ) Medicaid provides devices to these individuals through a managed care system.  Evaluating agencies are awarded contracts to pay for assessment as well as 12 hours of training with each new device.  Evaluations must indicate a medical need for a communication device, along with goals for implementation. 

Environments for assessment/intervention through the AZ Medicaid contract have included homes, communities and schools.  Perspectives offered in this article were also gained through five years working as a school speech-language pathologist in Phoenix, AZ, with an AAC caseload, and 22 years working with an ongoing AAC caseload of adults with developmental disabilities.

Starting with Questions from Families and Service Providers

Questions from families, teachers, and speech/language pathologists will be used as the primary means of organizing this blog.  We still have more questions than answers, and need to continue to look for additional research, clinical experience, and best practices to guide our services.

What is the best practice/theory for teaching a second language to speaking children?

Resources for English Language Learning (ELL or ESL) can be quite beneficial when teaching AAC, as robust AAC systems have rules for language that need to be learned, just like students who are learning the rules for a second language can build skills based on the foundational skills from their first language.  We need to help families and professionals understand that learning a language involves experiencing that language over time, and that conceptual knowledge can be mediated through Spanish (L1) to English (L2) or by both languages concurrently (multiple sources, referring primarily to the Revised Hierarchical Model, Kroll & Stewart, 1994).  In cases where children primarily hear/speak one language at home (L1), learning another language (L2) will build on concepts established in their first language, especially early stages of language proficiency (at the lexical level), where translated equivalents are connected to each other by excitatory links. We can consider AAC the L2 and L1 as either the English or Spanish that is heard at home.  If both English and Spanish are spoken at home, then we may need another category for AAC, as an L3. 


In 2010, Brysbaert & Duyck argued that there is little evidence to support separate lexicons and there is more evidence to make a distinction between language-dependent and language-independent semantic features.  The best AAC interventions for children learning communication should be able to activate language-independent semantic features.  Proficient bilinguals may dynamically adapt to contextual cues and selectively access information associated with the contextually cued language under certain conditions (Hoversten & Traxler, 2016).  A Bilingual Interactive Activation Plus (BIA+) model has been proposed for understanding the process of bilingual language comprehension that consists of two interactive subsystems: the word identification subsystem and task/decision subsystem.  Within the word identification subsystem the two languages are simultaneously (and unconsciously) activated at both the orthographic and phonologic level, then the final task is to use executive processing (located in other parts of the brain) such that participant expectations could impact outcomes.  In this model, AAC would be included in both the lexical phonologic (listening) and orthographic (visualizing) subsytems, with the addition of visual features of symbols rather than just the shape of words/letters as part of orthographic processing.  Over time, experiences with AAC would activate the task/decision subsystem to influence how more complex messages are constructed, independent of L1 or L2.  

What are the cultural/linguistic considerations when designing an AAC plan of intervention?

Before initiating a plan for using/learning an AAC system, those who will be supporting the individual need to have some agreement about what AAC looks like when families speak more than one language.  In addition to the myths and misconceptions of AAC that were dispelled by Romski & Sevcik in 2005, we also have to address misinformation that families may have received regarding bilingual language development. 

            Table 1. Myths about AAC use

Myth 1.   AAC is a “last resort” in speech-language intervention.
Myth 2.   AAC hinders or stops further speech development.
Myth 3.   Children must have a certain set of skills to be able to benefit from AAC.
Myth 4.   Speech-generating AAC devices are only for children with intact cognition.
Myth 5.   Children have to be a certain age to be able to benefit from AAC.
Myth 6.   There is a representational hierarchy of symbols from objects to written words (traditional orthography).

Some families were told by their pediatricians or other professionals that using a second language will be confusing and they should try to speak only English at home in order to make it easier on the child when he/she goes to school.  Therefore some families receive misinformation twice: once by being told they should only use one language, and again when they are told that it is best to wait to introduce AAC until a child has demonstrated certain pre-requisite skills (such as knowing/using a few signs or matching pictures to objects). The greatest hope we can impart to parents is the belief that their children can learn language.  In order to do so, we must recommend a robust communication system and work on strategies to teach the child about the symbols and rules that make up that system.

How do we encourage AAC use in the home if the home and school languages are different?

Language is an agreed upon set of symbols and rules that enables a community of people to interact and communicate with each other.  Therefore, each language and each community will have some symbols and rules in common and some differences.  Since expressive communication skills are built through experiences, it is only logical that individuals who come from homes where Spanish is spoken by at least one caregiver will have some knowledge of how words are used in that language, particularly as they relate to home routines.  An immersion experience, where the caregivers provide fluent language models supports bilingual language development, including development of beginning AAC skills. 

The first goal, therefore, is to teach communication partners about aided language input. They need to learn to simplify their language and point to key words/symbols on the AAC system as they talk.  Early communication on an AAC device should be telegraphic, with the verbal partner filling in the blanks.  When a parent wants to know if his child wants a cookie, the single word modeled on the device would be “WANT” followed by a gesture toward the cookie and the verbal word.  An extended model on the device would be, “WANT COOKIE” and when combined with speech may also say, “You WANT THAT cookie.” 

Early communicators need us to model without the expectation of immediate or exact imitation.  We should be ready to accept that early imitation (AAC babbling) will start with random selections on the device and should be followed by praise and excitement, not immediate correction. We can attribute meaning to any random selection and build experiences rather than force a child to imitate something that he/she never intended to say.  Providing a button that a child can use to independently switch between languages will allow him/her the freedom to explore and master words that are personally meaningful and interesting.  Fluent communication partners can choose which language to model and beginning AAC communicators can do the same when they start making selections on their own. 

Always keep in mind that everybody communicates, and to offer opportunities and experiences that help support a variety of communicative intents/functions (www.vantatenhove.com).  Any robust AAC system must include an organizational framework for categorizing words as well as rules for syntax/morphology.  Some categories will be very similar in both English and Spanish, particularly with regards to nouns (e.g., people, places, toys, foods).  More differences will be seen based on word use, word order, and morphology.  When we provide AAC intervention, we need to think about the first words that our students will be using, as well as how they will learn to combine or modify words to express their own thoughts and intentions over time.


           Table 2. Symbol-Based Robust Bilingual English/Spanish AAC Apps
Vocabulary
OS
Website
Bilingual Design
Organization
Avaz
iOS,
Android
no
Similar apps are available for both languages
Crescendo on Proloquo2go
iOS
Yes
Message window is bilingual and code switches with all languages
Basic Fitzgerald home page layout; Alphabetical for adjectives, verbs & fringe (in both languages); some core pronouns and verbs repeat on category pages;
Grid 3
iOS, Win10
no
Page sets are available for both languages, not bilingual by design
LAMP WFL
(bilingual ENG/SP)
iOS, Accent (Win10)
Yes
Clear the message window when switching languages
Starts from home page with icon sequencing – Similar motor plan for all words; Spanish is translated from English. Category pages are alphabetized in English and maintain position on Spanish pages
Snap + Core First
iOS & Win10
Yes
Message window is bilingual, maintains accurate pronunciation when switching
Fitzgerald core page; Topics and Lists (Categories) are in alphabetical order in English and don’t change position when switched to Spanish
Unidad
Accent (Win10)
Yes, but message window is not bilingual
Designed for bilingual semantic support with a similar motor plan across languages
WordPower 60 Basic/o
iOS and
NOVA chat
Yes
Only NOVA chat has user access to switch languages.
Message window must be cleared before switching languages.
Basic Fitzgerald layout; Alphabetical order for adjectives, verbs & fringe; some core pronoun phrases repeat on category pages; some Home page verbs link to category pages

What is the role of non-Spanish speaking SLPs when working with Spanish speaking students and families?  Can both languages be taught at the same time?

Typical bilingual children develop early vocabulary at about the same rate as monolingual children.  The ability to develop skills in two languages has been observed in children with developmental disabilities such as Down Syndrome, specific language impairment and autism (Angulo-Jiménez, 2018).  The rate at which children who need AAC develop language will depend on the interaction of several factors, including interest and perceived need/benefit of two languages as well as how they are exposed to these languages.  


We need to re-assure parents that early language concepts can be mapped through AAC, and again emphasize the importance of aided language input so that they are speaking directly to the child using AAC.  When careful attention is paid to how meaning is associated with the symbols and how the vocabulary is organized across languages, using both English and Spanish can strengthen understanding of how the symbols work for a variety of communicative purposes and across environments and partners. Some individuals who require augmentative communication have intact language systems and impaired articulation, but these are the exception.  It is our intention to reach young people who need communication supports way before they are teenagers.  The result in many cases is that when a communication device is introduced, expressive (and sometimes receptive) language learning will be mediated through that system. 

Young children learning English or Spanish experience periods where certain morphological or syntactical forms are over-generalized as they experiment with applying rules to words they are learning.  When teaching AAC skills, therefore, we should be aware of language patterns that are unique to each language, and attempt to modulate our early word choices to emphasize patterns that are similar rather than different.  For example, use of the word “MORE” can be easily generalized across languages, partners, and environments. We can demonstrate switching between languages to use this word in many different situations.  Using “I’m hungry” is more complicated, since the pattern in Spanish is different from other descriptors.  Requesting, “I WANT to EAT” or asking, “what do you WANT to EAT?” uses forms that teach AAC patterns that can be used over and over, across partners and languages. Therapists who do not speak both languages will need to have discussions with families or other bilingual speakers to determine which phrases will be most functional. 

Are there different developmental milestones and stages of language acquisition in Spanish and English?

All children move from using non-symbolic systems of communication (e.g., gestures and vocalizations) to symbolic means (primarily spoken or written words, but may also include sign language).  Basic developmental milestones for any language follows similar paths, moving from babbling to first words at about 12 months and then increasing to about 200 words (including 2 word phrases) by the end of the first year.  https://bilinguistics.com/wp-content/uploads/2013/10/Apples-to-Apples-for-Speech-and-Language.pdf  To emphasize the building blocks for AAC, and to provide options for spontaneous novel utterance generation, we need to practice with words that are most frequently occurring, referred to as “core words” when structuring supports in English (www.project-core.com). We still need a definitive resource for what these words are in Spanish- or in bilingual English-Spanish-speaking environments.

What are the best methods/words to model AAC and build literacy skills for a child who is bilingual?

When learning to read, the best instruction employs strategies that engage multiple processors (Adams, 1990):  orthographic (print), phonologic (listening), meaning (word level) and context (to achieve comprehension).  To build language and literacy skills, therefore, requires stimulation and integration of many parts of the brain. This can only occur through personally meaningful experiences, and the foundations of literacy and language builds from the speech a baby hears and the first sounds he/she makes.  As we structure AAC experiences, it is critical that we engage all these processors, so that meaning is achieved, not just a response to a stimulus.  We need to make sure that AAC is more than just, “Push this button when I put it in front of you and you will get something you like.”  Learning to recognize, read, and use words (including AAC symbols that represent words) involves using them in multiple contexts with different partners in varying environments.


The website www.project-core.com provides guidance for supporting young communicators as they move from gestural, non-symbolic forms of communication to symbolic use of words.  They even provide a list of 36 English “universal” core words that can be used across activities and contexts in the school environment. We do not have the same list for Spanish.  Table 3 provides a list of the most functional top 40 words in English, chosen with the intent of combining these words when modeling language.  Note that many of these words are used when teaching young children to read English.  Therefore, picture books and books for young children will offer multiple opportunities to practice these words. 

           Table 3: First 40 www.med.unc.edu/ahs/clds/resources/core-vocabulary
I
like
not
want
help
it
more
different
who
she
you
he
where
up
on
in
me
make
get
look
what
need
are
is
some
put
all
this
don’t
that
go
do
when
finished
can
here
open
turn
stop
over

Carol Zangari’s “Year of Core Words” (www.praacticalaac.org) covers a range of communicative functions, so we can practice asking questions, directing others, requesting, etc.  This can be the most explicit map for practicing and providing aided language input.  Parents can use these words in Spanish, knowing that they are supporting the function of communicating through AAC, strengthening semantic relationships with the symbols, and demonstrating skills that are similar in English.

Here is a link to the smart charts for the WordPower Basic 60 SS (SymbolStix) version: https://saltillo.com/chatcorner/content/31.   The smart charts for icon sequences (Unidad, Words For Life) can be found at www.aaclanguagelab.com.  Each month interventionists can practice a set of core words with the parent(s) in English.  Talk about how the English words/concepts could be translated into Spanish, and practice on the device in both languages.  After some practice finding the words, talk about family goals and brainstorm ways they can use the words throughout the month.  Focusing on just five core words during an activity, especially at first, gives more opportunities to practice.  

     Table 4. Year of Core Words – 40 Spanish words in 4 months

Month 1
Month 2
Month 3
Month 4
Again – otra vez
Eat – comer
Away
Big – grande
All done – (no más)
Get
Bad - mal
Busy
Different - diferente
Go – vamos
Come – ven
Do
Help – ayuda
Happy – feliz
Good – bueno
Drink – beber
Mine – mío
Here – aquí
It - lo
Feel - sentir
More – más
I/me – me
Make – hacer
He – Él
Not/don’t – no
Like - gusta
Now – ahora
In
Stop – parar
On
Off
Make - hacer
That - eso
Play - jugar
Read – leer
Out
Want – quiero, quieres
Put
There – allá
Some – poco
What – qué
This - esto
Thing – cosa
Tell – di
You –
(Give) – da
Where – dónde
(Where)  adónde
Who – quién
(help) - ayuda
 (Tell) - di
(Look) - mira


Many families have already had experiences with early intervention and the use of the sign “more” and will use the same sign when saying the word “más” in Spanish.  So start there and talk about many ways they can teach and use this word throughout daily routines.  Then look at the word “all done” and do the same thing.  For some families, this word is most often used in English, so talk about how to switch languages on the device, to model the English version with more frequency.  Share Let’s Teach Core resources from Saltillo with teachers, therapists, and other family members who speak English.  Here is a link for “Let’s Teach More:”  https://saltillo.com/downloads/chat/lets-teach-core/Let%27s%20teach%20more.pdf

In January particular attention should be paid to “want” and “don’t want” in order to address the assumption that a communication device is for making requests.  Encourage the parents to model asking “what” on the device.  This gives them more experience using words on the device, not just for requesting, but for asking and negating, as well.  It is important that the interventionists and families agree that grammar is not important on the device and that it is appropriate and should even be encouraged to model phrases on the device such as WHAT WANT and WHAT YOU WANT or NOT WANT.  At the same time, encourage them to verbally use appropriate grammar.  They can say a word or two while pointing to one symbol (on the device or on a printed display).  This method of aided language input has been described by multiple clinicians, including Jill Senner.  She recently offered a recorded webinar for Saltillo (https://saltillo.com/videos/communication-partner-instruction-in-aac).  In addition to pointing to symbols on the device, interventionists can provide families with printed and laminated versions of the device home page.  That way they can point to a symbol and say the word in either language.

When speaking with the speech/language pathologists who serve these students, provide additional ideas for activities to practice core words.  Great resources for activities with identified core words include: Assistiveware’s Core Word Classroom and the AAC Language Lab.  Although there is a fee for the Language Lab, the first year is included with purchase of one of the devices from Prentke Romich Company. 

Erin Sheldon and Caroline Musselwhite do a great job introducing their first set of four core words in their communication video series for Angelman Syndrome Foundation

The words for February include “like,” and interventionists can show families how to do a little charting activity of things their child likes or doesn’t like.  This is also an idea from Saltillo’s Chat Corner.  During the second month of intervention with a new device, talk more about customizing and personalizing the vocabulary so that the “About Me” page includes something about what the child likes.  Then talk about categories of words for eat/drink/play and what they watch on TV or videos.  Watch YouTube videos.  If appropriate for the child’s age, use Super Simple Songs, such as “Do You Like Broccoli Ice Cream?” https://www.youtube.com/watch?v=GOCroTBFlFw&t=6s.  For older students, show them how to use Tarheel Reader.  Here is a link to a story using “don’t like” and “do like”:  www.tarheelreader.org/2014/06/03/like-not-like/.   Use best practices for shared reading experiences by following the recommendations from Project Core (http://www.project-core.com/shared-reading/).

Realize Language (www.realizelanguage.com) offers great visuals in addition to collecting data on device use.  Whether the child is using English or Spanish (or both), the beginning communicator needs experiences with highly functional words throughout their day.  Creating word clouds and examining patterns of use will give information about the frequency and depth of aided language input and focus discussion around target vocabulary.

Implementation with Expanded Communicators

More research and direction is needed as to the best methodology for encouraging expanded grammar functions across languages.  Rules for syntax and morphology differ.  Young students are very likely to over-generalize patterns of use, in both languages.  We will need to move beyond just modeling to more explicit instruction and practice with students as they become more metacognitive about language structures.

We should not expect young children to be metalinguistic regarding language structures; we should just provide clear models in functional situations.  Handouts related to this topic are available from http://praacticalaac.org/praactical/presentation-handouts-on-aac-implementation/.  Guest speaker blog (Dr. Kimberly Ho) regarding moving beyond scripting and collaborating with Applied Behavior (ABA) interventionists using Verbal Behavior (VB) also describes how learning language on a speech output device can start with personally meaningful individual words that are modeled throughout the day and can build naturally to include word combinations and morphology when the child is ready, http://praacticalaac.org/praactical/aac-and-asd-beyond-scripting/.

According to Binger (2014) preschoolers can learn some rule-based linguistic structures with relatively little instruction (such as possession-entity) while other forms can be taught within play-based routines with aided language input (Agent-Action- Object, Entity-Locative, Possessive-Entity) relatively quickly.  Some achieved mastery during baseline while others took 3-8 intervention sessions. Average time spent in intervention for each target was 2.2 hours (30 min/session).  Although this study was with English-speaking children using AAC devices only in English, the device used has bilingual capabilities and a similar study could be replicated with play-based intervention taking place using aided language input with Spanish. 

For those families who are able to join us, we offer additional experiences to use core words during our Out And About activities in the community.  A guide for starting this type of group can be found for free at www.teacherspayteachers.com.   Some of our most important communicative functions that we practice are social greetings/manners, commenting (including giving opinions) and requesting.  We also try to design activities where we can practice with words used to describe or tell about the event or items we are using.  Many families include parents with limited English proficiency and siblings who are bilingual.  We encourage the families to practice in both languages so that they are developing schema related to the concepts being expressed, not just pushing a button to say a word or phrase. 

Some of our participants who have had more experience using their devices will be able to model expanded utterances.  We talk about language patterns and differences between English and Spanish.  One of my SLP colleagues, Sharon Hendrickson-Pfeil, also does bilingual community-based intervention (in addition to working in schools in Tucson, AZ).  She suggests the use of books on Raz Kids (www.raz-kids.com) as a way to share interactive videos with families and practice early sentence structures.  They use translated leveled books. 

Finally, keeping in touch with others who use AAC can also build more confidence and foster self-advocacy.  Some adults who use AAC have shared feelings of discrimination due to limited grammar skills.  I work with Adult Day Programs and the members there are always looking for ways to connect with others and share what they have learned (and are continuing to learn).  We use e-mail, YouTube channels and Facebook groups.  Look for us at www.closingthegap.com

References

Adams, M. J. (1990). Beginning to read: Thinking and learning about print. Cambridge, Mass: MIT Press.

Angulo-Jiménez, H. (2018). Bilingualism and Autism: Addressing Parents' Frequently Asked Questions. Perspectives ASHA SIGs, 3 (SIG 1), 98–105. doi: 10.1044/persp3.SIG1.98

ASHA collection of resources from the Office of Multicultural Affairs offers policy documents, guides and tips for addressing the needs of CLD students in schools, titled “Working with Culturally and Linguistically Diverse (CLD) Students in Schools.” © 1997-2015 American Speech-Language-Hearing Association. http://www.asha.org/slp/CLDinSchools/

ASHA Practice Portal on “Cultural Competence.” © 1997-2015 American Speech-Language-Hearing Association. http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935230&section=Key_Issues#Developing_Cultural_Competence

Gerber, S., Brice, A., Capone, N., Fujiki, M. & Timler, G., (2012). Language Use in Social Interactions of School-Age Children With Language Impairments: An Evidence-Based Systematic Review of Treatment. Language, Speech, and Hearing Services in Schools, 43, 235-249.

Goldstein, B.  (2012).  Bilingual Language Development & Disorders in Spanish-English Speakers.  Baltimore: Paul H. Brookes Publishing.

Goldstein, B. (2011). Cultural and Linguistic Diversity Resource Guide for Speech-Language Pathologists.  NY: Delmar, Cengage Learning.

Gutiérrez-Clellen, V. F., & Simon-Cereijido, G. (2009). Using language sampling in clinical assessments with bilingual children: Challenges and future directions. Seminars in Speech and Language, 30(4), 234.

Hoversten, L., & Traxler, M. (2016). A time course analysis of interlingual homograph processing: Evidence from eye movements. Bilingualism: Language and Cognition, 19(2), 347-360. doi:10.1017/S1366728915000115.

Kohnert, K., Yim, D., Nett, K., Kan, P. F., & Duran, L. (2005). Intervention With Diverse Preschool Children: A Focus on Developing Home Language(s). Language Speech Hearing Services in Schools, 36(July), 251–263.

Kroll JF, Van Hell JG, Tokowicz N, Green DW. The Revised Hierarchical Model: A critical review and assessment. Bilingualism: Language and Cognition. 2010; 13:373–381.10.1017/ S136672891000009X

Martin, C.D., Dering, B., Thomas, E.M., Thierry, G. (2009). Brain potentials reveal semantic priming in both the 'active' and the 'non-attended' language in early bilinguals. Neuroimage 47, 326–333.

McCord, M. S., & Soto, G. (2004). Perceptions of AAC: An Ethnographic Investigation of Mexican-American Families. Augmentative and Alternative Communication, 20(4), 209–227.

Perozzi, J. A., & Lourdes Chavez Sanchez, M. (1992). The Effect of Instruction in L1 on Receptive Acquisition of L2 for Bilingual Children With Language Delay. Language, Speech, and Hearing Services in Schools, 23(October), 348–352.

Pickl, G. (2011). Communication intervention in children with severe disabilities and multilingual backgrounds: perceptions of pedagogues and parents. Augmentative and Alternative Communication, 27(4), 229–44.

Robinson, N.R. & Solomon-Rice, P.L. (2009). Supporting collaborative teams and families in AAC. In G. Soto and C. Zangari (Eds.) Practically Speaking: Language, Literacy, and Academic Development for Students with AAC Needs, (pp.289-312). Baltimore: Paul H. Brookes Publishing.

Romski, M. & Sevcik, R. (2005).  Augmentative Communication and Early Intervention Myths and Realities.  Infants and Young Children, Vol 18, No 3, pp. 174-185.  © Lippincott Williams & Wilkins, Inc.

Sheng, et al (2013). Semantic Development in Spanish-English Bilingual Children: Effects of Age and Language Experience. Child Dev. 2013 May ; 84(3): 1034–1045. doi:10.1111/cdev.12015.

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Soto & Zangari (2009).  Practically Speaking:  Language, Literacy, & Academic Development for Students with AAC Needs.  Baltimore: Paul H. Brookes Publishing.


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